What does real-world walking mean to people with stroke? An interpretive descriptive study.

PURPOSE: Understanding personal experiences of real-world walking for stroke survivors could assist clinicians to tailor interventions to their clients' specific needs. We explored the research questions: "What does real-world walking mean to people after stroke and how do they think it can be better?" METHOD: Using an Interpretive Descriptive methodology, we purposively sampled eight stroke survivors who reported difficulty walking in the real-world. We sought diversity on key participant characteristics. Participants were interviewed using a semi-structured guide. Data were analysed with thematic analysis. RESULTS: Many found real-world walking, particularly in the outdoors, created opportunities for freedom from dependence and a visible step by step progress, which generated hope for future recovery. Conversely, when participants did not experience sufficient progress, they expressed negative emotions. Participants strove to overcome challenges to their walking goals using everyday routines, planning skills, and confidence building experiences to motivate themselves. They also drew on, and extended, social resources highlighting the relational aspects of real-world walking. CONCLUSIONS: Walking in their real-world provided a meaningful, desirable, but challenging goal for participants that required significant emotional effort. Successful progress in real-world walking builds confidence and hope and can contribute to psychological wellbeing by providing opportunities for successful mastery and social connectedness.IMPLICATIONS FOR REHABILITATIONReal-world settings can be unpredictable which makes walking in the real-world after stroke demanding.Positive experiences of walking in the real-world can provide significant psychological benefits to stroke survivors.Many survivors need to carefully concentrate on the act of walking in outdoor settings.Pre-planning routes, confidence-building experiences and developing daily routines may help patients overcome these challenges.

Interventions to improve real-world walking after stroke: a systematic review and meta-analysis.

OBJECTIVE: This study aimed to determine the effectiveness of current interventions to improve real-world walking for people with stroke and specifically whether benefits are sustained. DATA SOURCES: EBSCO Megafile, AMED, Cochrane, Scopus, PEDRO, OTSeeker and Psychbite databases were searched to identify relevant studies. REVIEW METHODS: Proximity searching with keywords such as ambulat*, walk*, gait, mobility*, activit* was used. Randomized controlled trials that used measures of real-world walking were included. Two reviewers independently assessed methodological quality using the Cochrane Risk of Bias Tool and extracted the data. RESULTS: Nine studies fitting the inclusion criteria were identified, most of high quality. A positive effect overall was found indicating a small effect of interventions on real-world walking (SMD 0.29 (0.17, 0.41)). Five studies provided follow-up data at >3-6 months, which demonstrated sustained benefits (SMD 0.32 (0.16, 0.48)). Subgroup analysis revealed studies using exercise alone were not effective (SMD 0.19 (-0.11, 0.49)), but those incorporating behavioural change techniques (SMD 0.27 (0.12, 0.41)) were. CONCLUSIONS: A small but significant effect was found for current interventions and benefits can be sustained. Interventions that include behaviour change techniques appear more effective at improving real-world walking habits than exercise alone.

Does clinic-measured gait speed differ from gait speed measured in the community in people with stroke?

OBJECTIVE: To compare the extent to which gait speed measured in the clinic setting differs from that measured in the community. DESIGN: Participants completed the 10-m walk test at a self-selected speed in a clinic SETTING. Following this they completed a 300-m community-based walking circuit that covered a variety of environmental conditions. Gait velocity was sampled at different points in the circuit. The same circuit and sampling points were used for all participants. Clinic gait velocity was compared to gait velocity measured on five occasions during the community-based circuit. SETTING: Physiotherapy clinic and local shopping mall. PARTICIPANTS: Twenty-eight chronic stroke patients who regularly accessed the community divided into two groups based on their gait velocity in the clinic. MAIN OUTCOME MEASURES: Walking velocity. RESULTS: Spearman rank correlation coefficient indicated that there was a strong correlation between the total time taken to walk the 300-m course and the clinic-based gait velocity (r = -0.88, P < 0.0001). A linear mixed model with repeated measures analysis revealed significant interaction between community measures for group A versus group B (F4,26 = 4.49, P = 0.0068) and significant differences across community conditions (F4,26 = 7.12, P = 0.0005). CONCLUSION: The clinic-based 10-m walk test is able to predict walking velocity in a community setting in chronic stroke patients who score 0.8 m/s or faster. However, for those who score less than 0.8 m/s in the clinic test, gait velocity in the community may be overestimated.

Determinants of physical health in frail older people: the importance of self-efficacy.

OBJECTIVE: There is continued uncertainty regarding the strength of association between performance-based and self-report measures of physical functioning, and of their relationship to self-efficacy and health-related quality of life (HRQoL). This study assessed the inter-relationships between such measures, and the predictors of 'physical' aspects of HRQoL in frail older patients. DESIGN: We used statistical models to determine the predictors of 'physical' HRQoL, according to the physical component summary score and the physical functioning domain of the 36-item short form (SF-36) questionnaire. SETTING: Patients were recruited from hospitals in Australia and New Zealand and followed up in their homes. SUBJECTS: Two hundred and forty-three frail older patients. MAIN MEASURES: Physical functioning was assessed using three performance-based measures (Timed Up and Go Test, gait speed and the Berg Balance Scale) and five self-report measures, including the modified falls self-efficacy scale, at three and six months after registration. RESULTS: A moderate association (r = 0.48-0.55) was found between each of the performance-based and self-report measures, including the SF-36 physical component summary score. Multiple linear regression analyses showed that the performance-based measures and falls self-efficacy predicted 33% of the SF-36 physical component summary score. Falls self-efficacy was the single highest predictor of both the SF-36 physical component summary score and SF-36 physical functioning domain. A curvilinear relationship was found between the SF-36 physical functioning domain and two variables: falls self-efficacy and the Berg Balance Scale. CONCLUSIONS: Although performance-based and self-report measures provide complementary but distinct measures of physical function, psychosocial factors such as self-efficacy have a strong influence on the HRQoL of frail older people.

Systematic review of progressive resistance strength training in older adults.

BACKGROUND: The aim of this systematic review was to quantify the effectiveness of progressive resistance strength training (PRT) to reduce physical disability in older people. METHODS: Randomized controlled trials were identified from searches of relevant databases and study reference lists and contacts with researchers. Two reviewers independently screened the trials for eligibility, rated their quality, and extracted data. Only randomized controlled trials utilizing PRT as the primary intervention in participants, whose group mean age was 60 years or older, were included. Data were pooled using fixed or random effect models to produce weighted mean differences (WMD) and 95% confidence intervals (CI). Standardized mean differences (SMD) were calculated when different units of measurement were used for the outcome of interest. RESULTS: 62 trials (n = 3674) compared PRT with a control group. 14 trials had data available to allow pooling of disability outcomes. Most trials were of poor quality. PRT showed a strong positive effect on strength, although there was significant heterogeneity (41 trials [n = 1955], SMD 0.68; 95% confidence interval [CI] 0.52, 0.84). A modest effect was found on some measures of functional limitations such as gait speed (14 trials [n = 798], WMD 0.07 meters per second; 95% CI 0.04, 0.09). No evidence of an effect was found for physical disability (10 trials [n = 722], SMD 0.01; 95% CI -0.14, 0.16). Adverse events were poorly investigated, but occurred in most studies where they were defined and prospectively monitored. CONCLUSIONS: PRT results in improvements to muscle strength and some aspects of functional limitation, such as gait speed, in older adults. However, based on current data, the effect of PRT on physical disability remains unclear. Further, due to the poor reporting of adverse events in trials, it is difficult to evaluate the risks associated with PRT.